Monday, July 4, 2016
Closing In On Retirement
A happy retirement dream: I am walking along the edge of a canyon that I have walked many times before. In physical reality this canyon does not exist. There is a large herd of buffalo stampeding through the canyon and making a lot of noise. On the opposing ridge there are 5 or 6 wolves trailing the herd. I see a family to my right and step into their yard to warn them about the wolves. The father reassures me that everything is under control and there is nothing to worry about. He has three small children playing behind him. He introduces me to a friend who I recognize from college and who has not aged well. I am sure that I remember his name but don't say it just in case I am mistaken. I realize that I am late and need to take a test, but it is a long way back to town. I think about asking my brother to pick me up and take me there - but I am already 15 minutes late.....
Closing in on retirement is not what I expected. I can remember sitting in 8th grade English class and wondering what it would be like to live to the old age of 40. Now that I am well past that and surprisingly healthy what is the best way to transition? Many people who retire these days are in a similar position. Chronic illnesses are better managed and most people anticipate a phase of active retirement, before moving on to less activity. One of the critical questions is how to make that transition as a professional. Besides feeling fairly healthy and fit, I also feel like I am at the top of my game as a psychiatrist. At a time when most psychiatrists are over the age of 55, should I try for a more gradual transition from patient care and teaching? Or should I just walk away? A lot of people seem to think that they have the answer. They have observed my work habits that included too many hours and too few compromises and have concluded "You will never retire!" The psychiatric colleague who I have known the longest has concluded that about herself. She thinks that she will end up being carted away some day from the job that she has worked for decades. I know I could not do that because I walked away from that setting 6 years ago - burned out and fully intending to call it quits. When you work a job for 22 years, it is easy to lose sight of the fact that there are many more reasonable jobs out there. Some of us just hunker down in longevity mode and don't see it until a crisis hits.
I put some preliminary communications out there. I concluded a couple of years ago that the most rewarding and efficient use of my time would be teaching - preferably psychiatric residents. Residency programs are much different today than when I was a resident. Business management has basically corrupted them. Today it is virtually impossible to be teaching clinical faculty anywhere and not have the same productivity expectations as psychiatrists in private practice. In other words there is the expectation that you can see large numbers of patients and continue be an innovative and creative teacher. Your salary is "justified" by the amount of billing that is generated. That has never really worked for me. I just attached one of my old storage devices to my current network this afternoon. Sitting there on that drive was a series of 10 PowerPoints on psychopharmacology from 2008. They were all 2 hour lectures and I came up with them from scratch after meeting with the residency director of a program I was affiliated with. The residents that year had requested that I teach the psychopharmacology lectures. I had peripheral involvement with the program until that point - largely due to the administrative restrictions. She thought it was really important for me to do it and I agreed that I would, but it was a significant time penalty for me. There was no productivity credit for preparing and delivering the lectures and no additional reimbursement. It was all done on my own time after taking care of all of the clinical work, billing and documentation. All done late at night and on the weekends - free gratis. Despite that, I was confident that I did a good job and the residents appreciated the work.
The point I am at in psychiatry, I am confident that I can teach nearly anything and do a good job of it. I am not confident at all that I want to transition into retirement seeing 75 - 100 very ill polypharmacy patients and teaching residents how to tweak that polypharmacy. You really don't need an experienced and knowledgeable psychiatrist to do that. I know that this is not really psychiatry, but somebody's business model of how to generate revenue and not consider all of the information that merits consideration. I can't sit by and look at people who have never had a manic episode being misdiagnosed with bipolar disorder, or the endless people with chronic stress in their lives expecting that medication will somehow change that, or the high functioning person with "ADHD" who really wants a prescription for a stimulant so they are not at a competitive disadvantage in college or professional school. Beyond that - I can't bite my tongue and listen to how they are seeing a therapist who is a "sounding board" and endlessly rehashing either their childhood or what happened last week and how that is supposed to be productive psychotherapy. I can tell them what they need to do to get better and if necessary do the therapy myself. And then there are the people with non-epileptic seizures, psychogenic mutism, chronic Lyme's disease, chronic pain, chronic daily headaches, reflex sympathetic dystrophy/complex regional pain syndrome and endless somatic permutations that need psychiatric care but walk in saying they don't: "I am here because my doctor thinks this is all in my head". There are the people with delirium, dementia, movement disorders, and abnormal MRI scans. I can see all of those people until my dying day, but it does not make an impact unless what I know can be amplified through current residents.
Before business managers ran medicine there was the kind of room I need at the current stage of life. Senior staff in those days were the people the house staff and attendings consulted. The absolute best teaching team that I ever worked on was a Nephrology team at Froedtert Hospital in Milwaukee. It was my last rotation in medical school. I recall finishing rounds at 10:30PM on the night before graduation and walking across the county hospital grounds to my apartment like it was yesterday. That team was staffed by two senior Nephrologists in their late 60s. The remaining team members included a Nephrology Fellow, two internal medicine residents, an intern and me. There was no myth that these senior staff somehow knew less or were less relevant. It was quite the opposite. We rounded twice a day until all of the consults and hospitalized patients were covered and the senior staff were the primary discussants. That myth is alive and well today, largely as a means to disenfranchise the tested clinical methods in medicine and make future generations of physicians dependent on organizations run by business managers rather than colleagues. Organizations that have promoted the idea that tests and arbitrary and unvalidated performance metrics are more important than spending enough time with patients and enough time discussing clinical scenarios with a broad range of physicians including the most experienced colleagues. It is no coincidence that the myth thrives in non-academic hospital environments staffed by generalists working impossible shifts. Knowledge and academics seems at its leanest point in the past 50 years.
At this point I am resigned to do what I can. I have offered my services but there are a significant number of reasons why none of that may come to pass. The hardest thing about retirement for me comes down to three issues. First, there are not nearly enough people to take my place. Psychiatry is possibly the best example of how a field can be decimated by political and business influences even in the midst an obvious shortage of services. Throughout my entire career there has been a shortage of psychiatrists and nobody has done a thing about it. Second, the very inefficient transfer of knowledge. I was personally taken out of the teaching loop for a long time by business practices that made it impossible for me to teach. What I know is not written down in texts and if I don't pass it along - it dies with me. That is counter to the evolution of how knowledge is passed from one generation to the next. Only American politics and business practices can stop evolution in its tracks. Finally, being an active part of a person's treatment and recovery from mental illness is important to me. In every case that involves an internal process on the part of the psychiatrist. In retrospect, I have attributed it to having great teachers and colleagues, a great memory, a particular personality characteristic, scholarship, or just being compulsive.
Despite what the measurement based people say, the validation of that process is totally subjective. At the end of the day or years/decades later - it is a person saying that you made a difference in their life and knowing that happened because you gave them the best medical advice that you could at the time. For me personally, it has also meant seeing people who have the most severe problems.
I won't miss any of the productivity based work any more than if I walked off any assembly line.
George Dawson, MD, DFAPA
I realized in the last couple of years that this blog factors into the transition as well. People have always asked me how I know something when I quote research or suggest a particular treatment or method of analysis. I think that part of what I am doing here on these pages is illustrating how I know something. Hopefully fellow psychiatrists, but especially medical students and residents will find it useful.
The graphic at the top of this post was downloaded from Shutterstock on July 4, 2016.